Provider Demographics
NPI:1568655702
Name:ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES
Entity Type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:ELWELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-651-6882
Mailing Address - Street 1:7 CLIFFORD DR
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-1250
Mailing Address - Country:US
Mailing Address - Phone:850-651-6882
Mailing Address - Fax:850-651-6692
Practice Address - Street 1:7 CLIFFORD DR
Practice Address - Street 2:
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-1250
Practice Address - Country:US
Practice Address - Phone:850-651-6882
Practice Address - Fax:850-651-6692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00125901223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3890Medicare UPIN